Anesthesia Coding Alert

Enhance your coding with expanded answers to 2 reader questions 

Subscribers raised questions about two reader questions/answers in the September Anesthesia & Pain Management Coding Alert. Our expanded answers will clarify the points made and make sure you code these types of injections correctly the first time.

64470 Applies to Medial Branch Facet Block

Question: Our physician administered a facet block via the patient’s medial branch nerves, above and below the C4-C5 facet. He used fluoroscopic guidance. How should I code this?

Answer: You should base coding for paravertebral facet joint and paravertebral facet joint nerve injections on the facet joint level instead of the number of individual nerves injected.

Example: For the C4-C5 facet joint, the provider can insert the needle into the facet joint itself (which would be one injection) or can perform two injections (one at each of the two nerves -- C4 and C5 paravertebral facet joint nerves [or medial branches] -- that innervate that joint). Either way, you report 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) only once. In this instance, base the number of “levels” on the number of facet joint levels your physician injects, not the number of needle insertions.

According to CPT parenthetical notes, you should report fluoroscopy separately when your provider uses fluoroscopy for radiologic guidance and documents it. Some carriers even state that a provider must use radiologic guidance to ensure the needle placement for facet joint injections. 

Code change alert: In the past, you would submit 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) for the fluoroscopic guidance during this procedure. But CPT 2007 deleted 76005, which means you should submit new code 77003 instead. The descriptor is the same one you’re used to for 76005; CPT 2007 just created a new section of codes for fluoroscopic guidance. 

Modifier reminder: Depending on the type of physical setting where your physician performs the injection, you might need to append modifier 26 (Professional component) to indicate that your provider only performed the professional component of 76005.

Remember 51 or 59 for Multilevel Injection

Question: Our physician administered a three-level lumbar injection for pain management. Which modifiers should I append for correct submission?

Answer: Knowing which CPT codes apply to the injection location determines whether you should append either modifier 51 (Multiple procedures) or 59 (Distinct procedural service). Because of this, you must know what anatomic structure your physician injected (facet joint, transforaminal epidural, trigger point injection, etc.) before you can code the procedure.

Lumbar lowdown: Lumbar facet joint injection codes (64475-64476) and lumbar transforaminal epidural injection codes (64483-64484) are designed for you to use the initial primary code to report a single-level injection and the second (add-on) code to report each additional level your provider injects.

According to CPT Surgery Guidelines, add-on codes are modifier 51 exempt because their associated RVUs (relative value units) are already reduced. Depending on your carrier’s preference for reporting multiple units of add-on codes, you might report two additional levels of facet joint or transforaminal epidural injections as two separate line items. If so, you’ll append modifier 59 to the second line item of add-on codes to indicate that you’re reporting a separate and distinct additional-level injection rather than mistakenly reporting a duplicate entry.
 
Trigger point tips: You should report trigger point injection (TPI) codes according to the number of muscles your provider injects. Submit 20552 when he injects one or two muscles and 20553 when he injects three or more muscles. These codes are an “either/or” selection -- you won’t report both codes for the same session on the same service date. You should report 20552 and 20553 with one unit of service, so modifiers 51 and 59 do not apply.

TPI checkpoint: If your provider performs multiple different procedures in the same region (including TPI), you might need to append either modifier 51 or 59. Before doing this, check whether the National Correct Coding Initiative (NCCI) edits bundle one of the procedure codes into the other.

Example: Your physician administers a single-level lumbar injection (64475, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) and one trigger point injection (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]) during the same encounter. This specific edit pair does allow you to report a modifier to bypass the bundling edit.

After checking your physician’s documentation, you find that he performed the two injections in separate and distinctly different anatomic locations (or at different sessions). That means you can append modifier 59 to the Column 2 code (20552) to break the bundle.

Final multiple-procedure note: The CPT Surgery Guidelines state, “When multiple procedures/services (other than evaluation and management) are performed at the same session, report the most significant procedure first with all other procedures listed with modifier 51 appended.” If the two procedures do not fall into an NCCI edit (such as 64475 and 64483, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level), some payers request that you append modifier 51 to the code with the lower RVUs.

Example: If you report 64475 and 64483 for the same visit, append modifier 51 to 64475.

Heads up: Many Medicare carriers request that providers do not report modifier 51 on the additional procedures performed. Their claims processing system automatically appends the modifier and processes the services correctly at 100 percent for the higher RVU code and reduces the amount for the lower RVU code. 

Source: Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.